What is the management approach for euglycemic ketoacidosis?

Management of Euglycemic Diabetic Ketoacidosis

Euglycemic diabetic ketoacidosis (eDKA) should be treated with the same core principles as classic DKA: fluid resuscitation, insulin therapy, and electrolyte management, with the critical addition of dextrose-containing fluids to prevent hypoglycemia. 1, 2

Diagnosis and Recognition

• eDKA is characterized by:

  • Blood glucose <250 mg/dL (often <200 mg/dL)
  • Arterial pH <7.3
  • Bicarbonate <15 mEq/L
  • Presence of ketones in blood or urine 1

• Common causes:

  • SGLT-2 inhibitor use (most common modern cause) 2, 3, 4
  • Pregnancy
  • Fasting states
  • Bariatric surgery
  • Reduced carbohydrate intake
  • Insulin pump failure 2

Treatment Algorithm

1. Fluid Resuscitation

• Begin with isotonic saline at 15-20 mL/kg/hour for the first hour 1
• Follow with 0.45% saline with dextrose at 4-14 mL/kg/hour based on hydration status 1
• Critical difference from classic DKA: Add dextrose early (5% dextrose) even with normal glucose levels to provide substrate for metabolism and prevent hypoglycemia 2, 4

2. Insulin Therapy

• Start continuous IV insulin infusion at 0.1 units/kg/hour after initial fluid resuscitation 1
• No initial insulin bolus is recommended 1
• Continue insulin infusion until ketoacidosis resolves (bicarbonate ≥18 mEq/L and pH >7.3) 1
• Monitor blood glucose hourly to prevent hypoglycemia; adjust dextrose concentration as needed 1

3. Electrolyte Management

• Potassium replacement:
  • Begin when serum K+ <5.5 mEq/L and adequate urine output is confirmed
  • Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO₄) to IV fluids 1
• Monitor electrolytes, BUN, creatinine, and venous pH every 2-4 hours 1

4. Monitoring

• Hourly: vital signs, neurological status, blood glucose, fluid input/output 1
• Every 2-4 hours: electrolytes, BUN, creatinine, venous pH 1
• Watch for complications: cerebral edema, hypoglycemia, hypokalemia, fluid overload 1

Special Considerations for eDKA

• If associated with SGLT-2 inhibitors:

  • Discontinue the SGLT-2 inhibitor immediately 3
  • Expect potentially prolonged duration of ketoacidosis due to drug half-life 4
  • Continue treatment until ketoacidosis resolves completely 1

• Resolution criteria:

  • Glucose <200 mg/dL
  • Bicarbonate ≥18 mEq/L
  • Venous pH >7.3 1

Transition to Subcutaneous Insulin

• Administer basal insulin 2-4 hours before discontinuing IV insulin to prevent rebound hyperglycemia 5, 1
• Consider low-dose basal insulin analog in addition to IV insulin to prevent rebound hyperglycemia 5
• Ensure patient is eating before transitioning to subcutaneous insulin 1

Discharge Planning

• Identify and address the underlying cause of eDKA 1
• Provide education on:
  • Diabetes self-management
  • Glucose monitoring
  • When to seek medical attention
  • Sick-day management (never suspending insulin during illness)
  • Proper medication administration 5, 1
• Schedule follow-up appointment prior to discharge 5, 1
• If SGLT-2 inhibitor-associated, discuss alternative medication options 3

Common Pitfalls in eDKA Management

• Delayed diagnosis due to absence of significant hyperglycemia 2, 3
• Failure to add dextrose early in treatment 2, 4
• Premature discontinuation of insulin when glucose normalizes but ketoacidosis persists 1
• Inadequate monitoring for hypoglycemia during insulin therapy 1
• Failure to identify and address the underlying cause 1

By following this structured approach, euglycemic DKA can be effectively managed with outcomes similar to classic DKA, despite its potentially confusing presentation.